SOAP Notes: It's Time for a Cleaning

By James Edwards, DC

I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.

But Dr. Ronald Short beat me to the punch with his outstanding article, "SOAP: A Chiropractic Perspective" [March 1, 2013 issue], in which he masterfully illustrated the problem. Hopefully, claim reviewers and documentation gurus will finally realize the difference between a chiropractic "assessment" visit and a chiropractic" treatment" visit. As Dr. Short so ably pointed out, to require orthopedic and neurological testing on each chiropractic visit is the equivalent of requiring a medical doctor to perform blood tests after each antibiotic pill. I could not have said it better myself.

It is important to remember that doctors of chiropractic are unique because we wear two very different hats. First, we are physicians who examine and diagnose (assessment) the patient. Then, after doing so, we carry out our treatment plan by providing care (treatment) to the patient. Failing to realize the distinct difference between a chiropractic "assessment" visit and a chiropractic "treatment" visit places undue, unfair and unnecessary examination and documentation requirements on doctors of chiropractic, and it is time for it to stop.

This problem has been known for years, yet no one has been successful in sensitizing the chiropractic "powers that be" about this unfairness. The American Chiropractic Association's Clinical Documentation Committee, during the process of authoring the third edition of the ACA Clinical Documentation Manual, attempted to directly address the issue by approving and submitting the following provision:

"It is important to understand that the chiropractic physician has two responsibilities to their patients.

"First, to perform the appropriate evaluation and management (E/M) service, including but not limited to the ordering of appropriate diagnostic imaging and lab work and/or other special testing in order to, diagnose and establish a treatment plan for the patient.

"Second; to provide chiropractic treatment consisting of but not limited to: Chiropractic Manipulative Therapy, Physical Medicine and Rehabilitation (PM&R) services, nutritional counseling, behavioral and lifestyle counseling including exercise therapy, and other services within the scope of chiropractic practice.

"This is similar to conventional allopathic medical practice whereby an MD/DO would provide an E/M service, order any appropriate tests in order to diagnose and establish a treatment plan for the patient and possibly refer the patient to a specialty provider to administer the appropriate treatment.

"Chiropractic is different than standard medical practice in that the DC provides both the diagnosis and the treatment. This can cause confusion when it comes to chiropractic documentation. It is important to note that less documentation is required for a routine visit for continuing care on an established care plan than on a patient encounter when an E/M service is performed."

Problem solved, right? Sorry, but no! That's because an ACA officer overruled the committee and got this very important provision stricken. Therefore, it does not appear in the documentation manual and a magnificent opportunity has been lost. If you are asking yourself why anyone would take that most unusual and unwarranted action – which makes "treatment" visit documentation far more cumbersome than it should be for practicing doctors of chiropractic – I suggest you ask the ACA for an answer.

There is another issue that is just as important as the denial of reimbursement. Many state licensing boards, including Texas (see "State Board Bullies: Lessons Learned," Feb. 26, 2010], are attempting to discipline doctors of chiropractic for not including ranges of motion, muscle testing, deep tendon reflexes, and/or orthopedic and neurological testing on each and every "treatment" visit, even though their "assessment" visit fully satisfied the necessary components to develop and implement a treatment plan. To be candid, I am becoming convinced that many of these state licensing board members do not understand or do not care about the difference.

I urge you access Dr. Short's article online and either print it out or save it to your computer along with this article. By doing so, you will be able to effectively communicate should you have claims unfairly denied or if your state licensing board attempts to discipline you unfairly.

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